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Board Meeting - Aircraft Accident Report - Crash after Encounter with Instrument Meteorological Conditions, During Takeoff from Remote Landing Site, New Mexico State Police Agusta S.p.A. A-109E, N606SP, Near Santa Fe, New Mexico, June 9, 2009 - Chairman's
Deborah A. P. Hersman
National Transportation Safety Board (NTSB), Crash after Encounter with IMC During Takeoff from Remote Landing Site, New Mexico State Police Agusta, Near Santa Fe, New Mexico, June 9, 2009, Washington, DC

Now, we'll begin with the second item on today's agenda – the accident report on the June 9, 2009, crash outside Santa Fe, New Mexico, involving a New Mexico State Police helicopter on a search and rescue mission.

On behalf of my fellow Board members and the entire NTSB staff, I offer our deepest condolences to the families and friends of the NMSP pilot and the passenger who lost their lives and to the patrolman who was injured in this accident. We recognize that your lives were forever changed when the crash occurred, and we know that nothing can replace the loss of your loved one or repair the trauma of a life-changing injury. But we do have the opportunity – and the obligation – to take every step possible to ensure that the lessons of this tragedy are well-learned and that the circumstances are not repeated.

Over the past several weeks, the Board Members have read the draft report and individually met with staff to discuss it. Today, however, is the first time that all of the Board members are meeting together to discuss the final draft.

Staff will make presentations on the major issues of the investigations. The presentations will be followed by a round of questions from the Board Members. We will then consider the conclusions, probable cause determination and proposed safety recommendations. Because these are the Board's actual deliberations on the report; it may be revised as a result of actions taken during this meeting. Approximately 30 minutes after we conclude, an abstract of this report will be available from the NTSB Public Affairs office and posted on the NTSB's website.

I'd like to express the Safety Board's gratitude to all those who responded on-scene immediately after the accident and who assisted the Board with the investigation. In particular, I'd like to recognize the New Mexico State Police; notably, Major Jesse Orozco who served as the party coordinator; Major Pat Werick, Lieutenant Pat Mooney, Officer Victor Gallegos, Mr. Marvin Janes, and Officer Larry Kauz of the Special Operations Unit and Aviation section. Your professionalism, integrity and willingness to embrace change and learn from this accident are examples for all of us.

Today, we will hear about the many factors that contributed to this accident. Among them, our investigators identified a tremendous pressure on the individuals, who perform important lifesaving work, to accomplish the mission. Performing search and rescue — saving lives — is noble and often heroic work, but a mission completion mindset can lead to poor decisions in an effort to “get it done” at any cost. Sadly, as in this case, the cost of getting it done can be too high.

We ask a lot of our emergency response personnel, like the accident pilot. In his position at the New Mexico State Police, he had multiple roles. He was Chief Pilot. He was a Line Pilot. And he also served as a Public Information Officer, or PIO. He was almost always on duty or on call.

As is too often the case, this accident followed a series of errors and omissions, which, if recognized and acted upon, could have prevented the loss of life. When this mission began, the pilot had already worked a full day and was called back to take this assignment. He initially turned it down due to concerns about the windy conditions. After reconsidering, he took with him a spotter who was not familiar with helicopter operations.

The challenge of locating the lost hiker was compounded by the fact that the hiker did not communicate in English which impeded her ability to provide the first responders with information to help focus the search. Then, there was treacherous terrain and worsening weather conditions which the pilot relayed to the dispatcher with increasing concern. When the pilot and spotter finally located the lost hiker, she was unable to make her way up to the helicopter. So the pilot climbed down the hill and carried her up, which could only have added to his fatigue and stress; never good ingredients for sound decision making. Meanwhile, the weather continued to worsen and it became dark, and neither crew member had brought warm weather gear or night vision goggles, again, adding to the challenges.

This afternoon, our investigative team will discuss the issues and confluence of events that facilitated this tragic outcome. Today, we will identify areas for improvement. We recognize that the NMSP, and other public and private entities, provide an essential service for all of us, and that it is difficult work. Additionally, it is important to note that the NTSB is not charged with conducting search and rescue training or operations, or with managing funding and resources to accomplish these important activities.

Our role at the NTSB is safety. Our role is not to judge but to investigate accidents and identify areas for improvement so that future accidents can be prevented. One thing we have learned from our investigations is that if safety is not the highest organizational priority, the organization may accomplish more missions, but there can be a higher price to pay for that success.

Dr Mayer, would you please introduce the staff.